JustCoding News: Inpatient, February 15, 2012

A great storyteller understands that it’s all in the details. Perhaps it’s the back-story about a particular character or maybe it’s the little facts peppered throughout the tale, but it’s the details that convey the essence of the story. In the world of coding, capturing all the necessary details is critical to accurately communicate and report the documentation in the medical record—in other words, to convey a patient’s story.

Consider injury codes in ICD-10-CM. Some codes for significant injuries tell only part of the story, as many of these codes also include a number of instructional notes to report additional codes for associated injuries (e.g., open wounds).

“You have to be very sensitive to those notes because a lot of them are needed in order for you to truly completely code the case the way it needs to be coded in ICD-10,” said Lolita M. Jones, RHIA, CCS, principal of Lolita M. Jones Consulting Services in Fort Washington, MD, who spoke during HCPro’s audio conference on December 13, 2011, “Musculoskeletal Injury Coding: ICD-9-CM vs. ICD-10-CM.”

Includes notes

Consider ICD-10-CM code S29 (other and unspecified injuries of the thorax), which lists a note that references strain of muscle and tendon of thorax. The instructional note tells coders to also report any associated open wounds as an additional code (S21.-), for which the dash indicates a missing digit that coders must fill in by looking up the more detailed codes.

ICD-10-CM code category S73 (dislocation and sprain of joint and ligaments of the hip) contains a fairly long list of what this code includes:

Avulsion of joint or ligament of hip

Laceration of cartilage, joint or ligament of hip

Sprain of cartilage, joint or ligament of hip

Traumatic hemarthrosis of joint or ligament of hip

Traumatic rupture of joint or ligament of hip

Traumatic subluxation of joint or ligament of hip

Traumatic tear of joint or ligament of hip

Even though the code category header refers to joint and ligaments, coders shouldn’t overlook the includes notes, which also reference “sprain of cartilage,” Jones said. There is also an instructional note to report any associated open wounds as an additional code.

Anatomy and physiology

Telling a patient’s story through ICD-10-CM codes requires a firm grasp of anatomy and physiology. Consider an anatomical drawing of muscle, tendon, and ligament of the upper arm that identifies the muscle, the olecranon, the radius, and ulna, as well as the tendon. Different codes pertain to different structures, therefore some joint codes may include cartilage or ligament or other structures such as bursa or tendon, Jones said.

“It’s important for you to understand what’s included when a particular structure is referenced and what you’re reading when you see those notes,” said Jones, who explained that documentation could reference a sprain, meaning a tear in a ligament, or a strain, meaning a tear in a muscle.

In the case of a torn tendon, physicians may indicate an extensor tendon or a flexor tendon or use some other abbreviation for a particular tendon. “There’s just so much clinical information that you’ll need to be aware of because coding in ICD-10 is just so detailed, and there are just so many opportunities for additional codes,” Jones said.

This code category also contains the following note: “Code first any associated spinal cord and spinal nerve injury (S34-).”

“So that’s very important. In ICD-10, that’s what’s to be reported first over and above the fracture of the lumbar spine and pelvis code, and if that code is to come out of the S32 category, it will have to follow the code for the spinal cord and spinal nerve injury” Jones explained.

Consider ICD-10-CM code S32.050 for a wedge compression fracture of the fifth lumbar vertebra. This level of detail is not always present in the documentation, said Jones, who explained that coders may see “fifth lumbar vertebral fracture” in the documentation, but it may not be clear whether it’s a wedge vs. a stable burst vs. an unstable burst.

“If you’re not seeing that type of detail … then this is going to be a documentation issue for you,” Jones said. “You want to start training the physicians to give you that level of detail. We really have so many opportunities in ICD-10 to collect more detailed information, and we need to take advantage of that by educating the physicians.”

“When you look through the injury chapter, take note of what really applies to your facility,” she said. “Don’t spend your time on the codes for conditions that you don’t really see. Focus on what really applies to your facility.”

Donna M. Smith, RHIA, senior consultant for 3M Health Information Systems in Atlanta, who also spoke during the audio conference, agreed that facilities must determine what’s going on within their institution and with their physicians. They should review charts and assess what information is missing to determine ways to address problems and ensure their facility will be able to report the increased granularity in ICD-10, she said.

“With injuries, you also want to make sure that your clinics and your professional services billing department know about the specifics also,” Smith said. “Certainly we can’t use a superbill like we have in the past where the diagnosis codes are already indicated, so we need to somehow come up with another method for obtaining the specific diagnoses.”

Spinal cord lesions

In ICD-10, coders can report spinal cord lesion codes in addition to vertebral fracture codes. ICD-10-CM code category S14 (injury of nerves and spinal cord at neck level) includes a code also note indicating the need to also report any associated fracture of cervical vertebra.

“You don’t want to miss out on an opportunity to report these codes if the patient also suffers from lesions at the neck level,” Jones said.

Note the level of detail in the following codes:

S14.111 (complete lesion at C1 level of cervical spinal cord)

S14.123 (central cord syndrome at C3 level of cervical spinal cord)

S14.136 (anterior cord syndrome at C6 level of cervical spinal cord)

S14.148 (Brown-Séquard syndrome at C8 level of cervical spinal cord)

S14.154 (other incomplete lesion at C4 level of cervical spinal cord)

“You may be thinking, ‘I never see that type of documentation’ or, ‘Have we seen it and didn’t really pay attention to it because there was no real opportunity to report it to this level of detail in ICD-9?’ ” Jones said.

Spinal cord injuries are classified as either:

Incomplete: The ability of the spinal cord to convey messages to or from the brain is not completely lost. People with incomplete injuries retain some motor and sensory function below the injury.

Complete: A complete injury results in a total lack of sensory and motor function below the level of injury.

Incomplete spinal cord injuries, in which some of the nerve tracts and motor sensory functions remain in tact, typically involve a number of syndromes, each of which has its own ICD-10-CM codes:

Anterior cord syndrome, which may be due to a hyperflexion injury, will cause motor deficits. The cord damaged, and the potential for recovery is poor.

Central cord syndrome is the most common form of incomplete spinal cord injury, often due to a contusion within the spinal cord or sometimes occurs in patients over the age of 50 due to a weakening of the vertebra and disc. The brain’s ability to send and receive signals to and from parts of the body below the site of injury is reduced but not entirely blocked.

Brown-Séquard syndrome, in which half of the spinal cord is affected, is one of the less common incomplete spinal cord injuries.

Posterior cord syndrome, which is the least common type of incomplete spinal cord injury, results in loss of sensory function (e.g., pain, temperature, and vibration).

Note that while these syndromes each have their own ICD-10-CM codes (listed above), coders would use ICD-10-CM code S14.154 for other incomplete lesion at the C4 level, Jones said.

“So there is a catch-all because I understand that new syndromes are not necessarily being diagnosed every day, but they do come up,” Jones said. “So we are covered there in ICD-10 with the other category or other classification.”

Complications

People who survive a spinal cord injury will most likely experience medical complications (e.g., chronic pain) as well as increased susceptibility to respiratory and heart problems. Coders may need to reference the nervous system section of ICD-10-CM to report chronic pain or they may need to go to the digestive system to report bladder dysfunction or the genitourinary system to report bowel dysfunction.

Some patients may suffer surgical complications, for which there are also ICD-10-CM codes (e.g., categories T80–T88 in the injury chapter [19]), including:

Bleeding

Infection

Spinal fluid leaks

Instrument failure

Many injury codes require a seventh character to identify the episode of care:

A (initial encounter)

D (subsequent encounter)

S (sequel)

“It’s so important to have clean and comprehensive documentation even if these patients come back for additional care,” Jones said. “For example, for a sequela, you’re going to need some information about that original injury. And depending on the facility that you’re in, that information may not be in the current encounter or current record, so you may need to go back to a historical record or file.”

Editor’s note: E-mail questions to Managing Editor Doreen V. Bentley, CPC-A. To learn about the major differences between ICD-9-CM codes and ICD-10-CM/PCS codes, sign up to participate in The JustCoding Virtual Summit: ICD-10-CM and ICD-10-PCS, which will take place February 29–March 2. During this three-day event, you will have the opportunity to hear from an array of experts, who will share guidance for the challenges of ICD-10 preparation and implementation. You will also be able to network with your peers and participate in question and answer sessions—all without ever having to leave your office.

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